Medical Power of Attorney (MPOA) Form

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Updated August 11, 2022

A medical power of attorney form (MPOA) allows a person (principal) to select an agent to make health care decisions on the principal’s behalf. The agent’s powers are effective after the principal becomes incapacitated or cannot make decisions on their own.

When making decisions, the agent must follow the principal’s preferred treatment options written in their Living Will (included in the MPOA).

Signing Requirements – Depends on the State where the Principal resides.

By State

Table of Contents

What is a Medical Power of Attorney?

A medical power of attorney (MPOA) is a designation made to select a person (agent or attorney-in-fact) to make health care decisions on behalf of someone else (principal).

If there is a dispute on whether the principal can make their own decisions, it will only go into effect after a licensed physician has deemed the principal incapacitated.

It’s recommended for a person that makes a medical power of attorney to also create a living will to write their treatment preferences for an agent to follow.

Medical POA vs Living Will


A medical power of attorney lets a person select their preferred treatment options with the use of choosing an agent to carry out their wishes. The agent will have full authority to make any type of decision to prolong or withdraw life-sustaining treatment.


A living will allows a person to select their preferred treatment options without the use of an agent. A living will directs medical staff their intentions to prolong or withdraw life-sustaining treatments depending on their condition.

Statutory Forms

STATE STATUTORY FORM LAWS
 Alabama Advance Directive for Health Care § 22-8A-4(c)(4)
 Alaska Advance Health Care Directive AS 13.52.010
 Arizona Health Care Power of Attorney § 36-3224
 Arkansas Durable Power of Attorney for Health Care

§ 20-6-103

 California Advance Health Care Directive PROB § 4701
 Colorado Medical Durable Power of Attorney

§ 15-14-506

 Connecticut Appointment of Health Care Representative Sec. 19a-575a
 Delaware Advance Health Care Directive § 2505
 Florida Designation of Health Care Surrogate § 765.202(1)
 Georgia Advance Directive for Health Care § 31-32-4
 Hawaii Advance Health Care Directive Form § 327E-16
 Idaho Living Will and Durable Power of Attorney for Health Care § 39-4510
 Illinois Durable Power of Attorney for Health Care 755 ILCS 35/3(b)
 Indiana Health Care Representative Appointment 755 ILCS 45/Art. IV
 Iowa Durable Power of Attorney for Health Care Decisions § 144B.5
 Kansas Durable Power of Attorney for Healthcare Decisions § 58-632
 Kentucky Advance Directive § 311.629
 Louisiana Medical Power of Attorney RS 28:223
 Maine Health Care Advance Directive Form

§ 5-805

 Maryland Advance Directive § 5-603
 Massachusetts Health Care Proxy § 201D-2
 Michigan Durable Power of Attorney for Health Care § 700.5501(b)
 Minnesota Health Care Directive

§ 145C.16

 Mississippi Advance Health Care Directive § 41-41-209
 Missouri Durable Power of Attorney for Health Care § 404.822
 Montana Durable Power of Attorney for Health Care § 53-21-1304
 Nebraska Power of Attorney for Health Care § 30-3404
 Nevada Durable Power of Attorney for Healthcare Decisions NRS 162A.860
 New Hampshire Advance Directive Section 137-J:20
 New Jersey Medical Power of Attorney (proxy) § 26:2H-57
 New Mexico Advance Directive for New Mexico § 24-7A-4
 New York Health Care Proxy PBH § 2981
 North Carolina Health Care Power of Attorney § 90-321
 North Dakota Health Care Directive § 23-06.5-17
 Ohio Health Care Power of Attorney Section 1337.17
 Oklahoma Advance Directive for Health Care § 63-3101.4
 Oregon Advance Directive for Health Care ORS 127.527
 Pennsylvania Durable Health Care Power of Attorney § 5471
 Rhode Island Durable Power of Attorney for Healthcare § 23-4.10-2
 South Carolina Health Care Power of Attorney § 62-5-504
 South Dakota Durable Power of Attorney for Health Care § 59-7-2.1
 Tennessee Advance Directive for Health Care § 68-11-1803(b)
 Texas Durable Power of Attorney for Health Care § 166.161
 Utah Advance Health Care Directive § 75-2a-117
 Vermont Advance Directive for Health Care 18 V.S.A. § 9703
 Virginia Advance Medical Directive § 54.1-2984
 Washington Durable Power of Attorney for Health Care § 11.125.100
West Virginia Medical Power of Attorney § 16-30-4
 Wisconsin Power of Attorney for Health Care § 155.30
 Wyoming Advance Health Care Directive § 35-22-403

Signing Requirements

A witness cannot be a person that is related to the principal, agent or be a beneficiary in the principal’s last will and testament. If a notary is required, the notary may not act as a witness.
STATE SIGNING REQUIREMENTS LAWS
 Alabama Two (2) Witnesses § 22-8A-4(c)(4)
 Alaska Notary Public or Two (2) Witnesses AS 13.52.010(b)
 Arizona Notary Public or One (1) Witness § 36-3221(A)(3)
 Arkansas Notary Public or Two (2) Witnesses § 20-6-103(c)
 California Notary Public or Two (2) Witnesses § 4701(e)
 Colorado No law (Notary Public recommended)

§ 15-14-506

 Connecticut Two (2) Witnesses § 19a-575
 Delaware Two (2) Witnesses § 2503(b)(1)(d)
 Florida Two (2) Witnesses § 765.202(1)
 Georgia Two (2) Witnesses § 31-32-5
 Hawaii Notary Public and Two (2) Witnesses § 327E-3(1)
 Idaho No law (Notary Public recommended) § 39-4510
 Illinois One (1) Witness 755 ILCS 45/4-5.1
 Indiana One (1) Witness § 16-36-1-7(b)(3)
 Iowa Notary Public or Two (2) Witnesses § 144B.3(b)
 Kansas Notary Public and Two (2) Witnesses § 58-632
 Kentucky Notary Public or Two (2) Witnesses § 311.625(2)
 Louisiana Two (2) Witnesses § 224 (A)
 Maine Two (2) Witnesses § 5-803(2)
 Maryland Two (2) Witnesses § 5–603
 Massachusetts Two (2) Witnesses § 201D-2
 Michigan Two (2) Witnesses § 700.5506(4)
 Minnesota Notary Public or Two (2) Witnesses § 145C.03(5)
 Mississippi Notary Public or Two (2) Witnesses § 41-41-205(2)
 Missouri Notary Public § 404.705(3)
 Montana Two (2) Witnesses § 50-9-103
 Nebraska Notary Public or Two (2) Witnesses § 30-3404(5)
 Nevada Notary Public or Two (2) Witnesses NRS 162A.790
 New Hampshire Notary Public or Two (2) Witnesses § 137-J:14
 New Jersey Notary Public or Two (2) Witnesses § 26:2H-56
 New Mexico Two (2) Witnesses § 24-7A-4
 New York Two (2) Witnesses PBH § 2981(2)
 North Carolina Notary Public and Two (2) Witnesses § 32A-16A(3)
 North Dakota Notary Public or Two (2) Witnesses § 23-06.5-05(d)
 Ohio Notary Public or Two (2) Witnesses § 1337.12(1)(b)
 Oklahoma Two (2) Witnesses 63 O.S. § 3101.4(A)
 Oregon Notary Public or Two (2) Witnesses § 127.515(2)
 Pennsylvania Two (2) Witnesses § 5452(b)(2)
 Rhode Island Notary Public or Two (2) Witnesses § 23-4.10-2(9)
 South Carolina Notary Public and Two (2) Witnesses § 62-5-517
 South Dakota Notary Public or Two (2) Witnesses § 34-12D-2
 Tennessee Notary Public or Two (2) Witnesses § 34-6-203(a)(3)
 Texas Notary Public or Two (2) Witnesses § 166.154
 Utah One (1) Witness § 75-2a-107(c)
 Vermont Two (2) Witnesses § 9703(b)
 Virginia Two (2) Witnesses § 54.1-2983
 Washington Notary Public or Two (2) Witnesses § 70.122.030
West Virginia Notary Public and Two (2) Witnesses § 16-30-4(a)
 Wisconsin Two (2) Witnesses § 155.10(1)(c)
 Wyoming Notary Public or Two (2) Witnesses § 35-22-403(b)

How to Get Medical POA (4 steps)

Step 1 – Select Your Agent

The Agent that you select will have the responsibility of making your decisions based on your health care situation. Therefore you will want someone that you trust and is aware of your basic medical history (such as heart conditions, medication, allergies, etc.)

  • Successor (2nd) Agent – Individual selected only if the primary agent is not able to fulfill their duties. Co-agent authority is not usually allowed, must be the decision of 1 person.
  • Compensation – You have the option to set up compensation for the agent selected for lodging, food, and travel costs.

Step 2 – Agent’s Decisions

The decisions you give your agent related to your health care is up to you. You can allow your agent to make any type of decision that presents itself or you could limit your agent to only certain types of decision making. The more detailed you are as to what your agent can and cannot do will enhance the medical staff on your health intentions.

  • Example –  Requesting the agent to refuse life support if there is little to no chance of a full recovery.

The following powers of the agent should be written:

  • Surgical Treatments
  • Nursing Home Treatment/Care
  • Hospitalization
  • Medical Treatment
  • Psychiatric Treatment
  • HomeStay Care
  • Organ Donation
  • End of Life Decisions

Step 3 – Attach a Living Will

A living will is a highly recommended option to be attached to any medical power of attorney. In addition to having someone speak on their behalf, a living will outlines a person’s end-of-life treatment selections.

For example, if a person should become in an incapacitated state with no chance for a cure, they can select to withhold life-sustaining methods to keep them alive. In addition, it allows the selection for organ donation and other post-death options.

Step 4 – Sign & Complete

The principal and Agent must sign in accordance with their respective State Signing Laws. In most cases, the form may be signed in the presence of two (2) witnesses or notary public, and sometimes both. After this has been legally authorized the document becomes valid to be used. The principal must be thinking freely during the creation of this form.

The Agent should carry an original copy of their form and will most likely need to present it during every occurrence. It is recommended to give a copy of this form to your primary care physician.

Sample

MEDICAL POWER OF ATTORNEY

 

1. APPOINTMENT OF HEALTH CARE AGENT

I, [PRINCIPAL NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Principal”) hereby appoint, [AGENT NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Agent”) as my Agent to make any and all medical decisions on my behalf, except to the extent I limit those decisions in this document. This power of attorney takes effect if my doctor certifies in writing that I can no longer make my own health care decisions. My agent can be reached at the following contact information:

Home Phone: [X] Work Phone: [X]

Cell Phone: [X] E-Mail: [EMAIL]

2. LIMITATIONS ON MY AGENT

My agent is authorized to make all medical decisions on my behalf EXCEPT for the following: [LIST LIMITATIONS]

3. APPOINTMENT OF ALTERNATE AGENT

If my agent appointed above is unable or unwilling to serve as my agent, I appoint the following person(s) to serve as agents in the order set forth below with the authority to make health care decisions on my behalf as provided herein:

a. First Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [X]

b. Second Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [X]

4. ORIGINAL AND COPIES OF THIS DOCUMENT

The original document is/will be filed in the following place: [LOCATION]

I have/will provide copies of my medical power of attorney to the following: [NAME(S)]

5. DURATION

Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I cannot revoke this document during the time I am considered incompetent to make my own decisions.

(If applicable Initial and Check)

[INITIALS] ☐  (OPTIONAL) This power of attorney shall expire on [XX] of [MONTH], 20[XX].

6. PRIOR MEDICAL POWER OF ATTORNEY

By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have executed.

7. EXECUTION

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC

OR

YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES NOT RELATED BY BLOOD OR MARRIAGE.)

SIGNATURES

I /We hereby execute this document on [XX] day of [MONTH], 20[XX]

in the City of [CITY], State of [CA].

Principal’s Signature _____________________          Print Name ______________________

Agent’s Signature _____________________               Print Name ______________________

1st Alt. Agent’s Signature ____________________    Print Name ___________________

2nd Alt. Agent’s Signature ____________________  Print Name ___________________

NOTARY ACKNOWLEDGMENT

STATE OF [STATE]

[COUNTY] County, ss.

On this [XX] day of [MONTH], 20[XX], before me appeared

[NAME], as Maker of this Medical Power of Attorney who proved to me through government-issued photo identification to be the above-named person, in my presence executed foregoing instrument and acknowledged that (s)he executed the same as his/her free act and deed.

Notary Public

Print Name: _____________________

My commission expires: _____________________                                                            Seal:

WITNESS STATEMENT AND ACKNOWLEDGMENT

I am not the person appointed as agent or successor agent in this medical power of attorney. I am not related to the maker of this document by blood or marriage. I am not entitled to any portion of the maker’s estate, nor do I have any claim against the maker’s estate. I am not the attending physician of the maker or an employee of the attending physician. I am not involved in providing direct patient care to the maker and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.

SIGNATURE OF FIRST WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

SIGNATURE OF SECOND WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

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